presentation Venetia Young at Prime Masterclass Croydon 01/11/2010

1. Frequent attenders – a
family systemic approach
Dr Venetia Young
GP, Bishopyards Surgery
(now the Lakes Medical Practice)
Penrith, Cumbria, England
UK

2. Bishopyards, Penrith
Small market town – population 20,000
5500 patients. 5 doctors (3 WTE), 2 nurses,
pharmacist
Consultations of more than 5 in Jan-March 2007
with GP in surgery
163 patients 1025 appointments. 3% of list
25% on antidepressants
Top 50 33% on antidepressants
Only one child
High proportion middle aged women

3. Frequent attenders audit
Top 5 – 3 major mental illness in contact
with mental health services, one severe
eating disorder, one social problem
10 with depression and anxiety.
2 with severe illness (both died)
7 with straightforward physical illness
26 multiple symptoms in which stress
played a part.

4. Sheffield (UK) Study
Waller and Hodgkin 2000
9 practices
1.3% patients generated 8.3% of consultations
(20pa)
3.6% patients generated 17.6% of consultations
(15pa)
42% on antidepressants 20pa cf 9% of
population
22% of FA had no chronic disease
1/3 repeated behaviour the next year

5. How was this managed?
Discussed with GPs
10 patients in referral process for PCMH team
CMHT contacted re top 3
Eating disorder patient admitted
Social problem family seen jointly at scheduled
appointments as there were multiple medical problems
Remaining frequent attenders noted and 15 worked with
by VY alone: genogram, ICE elicited, stress cycle and
hyperventilation explained, breathing exercises taught,
HADS, depression treated where appropriate,
3 patients offered regular routine follow up.

6. continued
Training – all staff on stress management and
health related anxiety
2 GPs, pharmacist and HCA on Positive Mental
Training- self-hypnosis CDs
Regular meetings with HV
Better focus with PCMH team
Change in appointment system
Cultural shift - Active management
Less use of locums

7. One year on in Penrith
44 patients seeing GP 5 or more times,
compared with 163
1 consulted 10 times compared with 11
Less than 1% of list, compared with 3%
18 male 31 female
18 not on Chronic Disease register
19 Hypertension, 4 Mental health, 2 DM, 2
cancer
8 under 20, 6 in 20-40, 5 in 41-50, 9 in 51-60, 8
in 61-70, 8 in 71-80.
Saving 200 appointments over 3 months

8. Some cases
Margaret
62 Divorced.
Pain in head, neck, shoulders, knees and back.
Dyspepsia. Migraine. Hypertension. Carer
Genogram
Reading self help leaflets
Stress cycle explained
Breathing and relaxation technique
Solution focussed questioning
Regular follow up: 5 appointments 120 minutes in all.

9. Case 2
Hilda 65
Type 2 DM on oral medication – poor control HbA1c 8.8
Barrett’s oesophagus
Severe anxiety disorder
CBT
Work with her and daughter
Medication – low dose escitalopram
Breathing and relaxation
Regular FU

10. Hilda 2010
DM well controlled for 2 years, HbA1c 6.6
reduction in medication
Barrett’s oesophagus improving endoscopically,
no dyspeptic symptoms
Appointments every 8 weeks
Anxiety gone: no panic attacks for 2 years, no
worries about hypos, no anxieties about
endoscopy
Coping strategies: taking a step back from family
dynamics, breathing, exercise

11. Patient comments
Rachel 35 - pleased to have diagnosis of
ME and not to have to pester the doctors
any more
Jo 68 - phoning doctors was a sign of not
being well
Mark 45 – phone number not near phone
Liz – 32 finally referred for psychotherapy

12. What are the patients’ needs?
Medically unexplained symptoms
Distress – relationships, work, school, money,
housing.
Depression and antidepressants
Anxiety disorders especially health related
anxiety need recognition.
Major mental illness
Good quality self-help literature
Appropriate referrals

13. Skill implications for whole team?
Active management not reactive
Good assessment
Eliciting patients’ backgrounds
Explaining stress and its effect on the body
Explaining hyperventilation
Managing affect in consultation and on phone
Diagnosing sub-syndromal depression
Therapeutic skills for watchful waiting
Noticing the frequent attender
Noticing the medication abuser
Using self-help materials

14. More advanced skills
BATHE
SFBT
CBT
Hypnotherapy
NLP
EFT (Tapping)
Human Givens approach- enhanced CBT
Systemic (Family Therapy)

15. The Primary Care Team and the
wider community
Community resources: young mothers,
middle aged women, lonely elderly
Mental health organisations
Social care organisations
Third sector

16. Further updates
Two practices have merged, with different frequent attender
problems
GP trainees and medical students given data to interpret
PCMH meetings monthly in practice: school nurse, health visitor,
community psychiatric social worker, primary care mental health
worker.
Plan to start a group for 45-60 yr old women who are beginning to
attend frequently.
MIND – charitable organisation – developed a sound recovery focus
Menopause evening – 50 women plus nurses and doctors
Training afternoon for 95 patients with COPD
Systemic Training in all 11 practices in locality on genograms,
breathing and stress cycle
Training for all staff on personality disorders

17. ‘A pain in the neck?’
The use of a systemic lens helps the clinician to
understand that if a community is not meeting
the needs of groups of its people, then they will
present in bigger numbers with multiple
symptoms to their primary care organisation.
The same applies to families failing to meet
emotional needs of their members
Clinicians will have frequent attenders if they
can’t explain MUS

18. References
Waller and Hodgkin: General Practice -
demanding work 2002 Radcliffe
Asen, Tomson, Tomson and Young: 10 minutes
for the family, Routledge 2004
Larivara et al 1996 developing a family systems
approach to rural healthcare: dealing with the
heavy user problem. Families, Systems and
Health 1996 14; 291-302
Kroenke and Mangelsdorf 1989 American
Journal of Medicine 86 262-266
McDaniel et al 2004 Family Oriented Primary
Care Springer Verlag